Laserfiche WebLink
Fop, 4rL 0 r,t fi 4fl or 0aI�. <br /> SAN JOA(U!L.,, JNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL �+�: :H DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUATION AFE 1.6 .� <br /> AME OF FACILITY 1weito- C Y\ L)c45 SWEEPS CODE Z7-:� + <br /> RDRESS l5gc) V� 05hlvt ANK 1D ri 7J�1 1-7 �f <br /> TANK SIZE I I1,Do C) UEL TYPE dLese1 <br /> 1[. GENERAL SITE HISTORY <br /> Is permit current' es o ermit >L! a itity Status Code oc.Soil/GW Cont es o <br /> umber of Tanks at facility gen sof Tanks(if available) ype of Tank teeE rgt ngl Dual <br /> I I I. TANK HISTORY Revy"C ed <br /> as Tank tested? es o ailed precision test ? es a If yes, give date(s) / <br /> as a repair made to the tank system? Yes No 11f yes, what was repaired7l <br /> Jas repair done under inspection? es o ere soil samples ana yzed? es la TXE PH-G PN-D 4/EDO <br /> ype of failure/discharge arastrophic [on4t,mteakage ver ill known ther: <br /> Iv. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> oil Samptes Received es o epth to Ground Water of/Yea verage Annual Precipitation N= 4 0-25 <br /> -Site Wells} es o umber & Type Err am ub <br /> S Score S Score 5 Score <br /> istance to Wells) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if Oif 0 if <br /> R ondition R condition R ondition <br /> Site Feature - Leaching Potential Analysis E 's met E is met E is met <br /> tZ1310 4iniffmim Depth to groundwater from the Soit Sampte (feet) >100 1-100 25-50\1 <br /> 13` ractures in subsurface (appties to foothills or mountain areas) None G Unknown resent <br /> average Annuat Precipitation (inches) XXXXXXI <10 9 10-25 xxxxxxx 26-40\2 <br /> nn-Made conduits which increase vertical migration <br /> of leachate (i.e., septic systems, water wells, ponds) None Unknown resent <br /> Inique site features: Recharge area, coarse soil, nearby wefts. At least ore than <br /> xxxx None one one <br /> COLUMN TOTALS»-TOTAL POINTS + 2 + <br /> ample Resuit: (B € X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> N D 54 ✓} 6 T X E a T X E <br /> �t''�7`` MAXIMUM ALLOWABLE a-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> -ample Result: IGASOLINE 1000 100 10 <br /> A` (F H AXIMUH ALLOWABLE TPH LEVELS (PPM) IESEL 10,000 1000 100 <br /> ITE <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth r_5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTX&E are not appticable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1, Are BTX & E or TPH Concentrations > Allowable Levels Yes ✓ ','� , " �'�"+' <br /> 2. Recommend Si cc Ctosure es o If Yes, Refer to Site mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR <br /> .ONCUR WITH STAFF RECOMMENDATION FOR CLOSURE ES 0 EFERRED 0 SITE MITIGATION FOR EVALUATION E5 0 <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILD / ! <br /> AME OF <br /> .VALUATOR <br /> EH 23 80 (UGTWKSHT)\5190 <br /> EH 29 80 <br />